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Psych Skills Pharmacy Presentation 2012 Chelsea Markle, PharmD Dick Miyoshi, RPh
LA Aripiprazole LA Iloperidone Pimavanserine ECT Haloperidol Fluphenazine Thioridazine Loxapine Perphenazine Chlorpromazine Clozapine Risperidone Olanzapine Quetiapine Ziprasidone Aripiprazole LA Risperidone (2003) Paliperidone (2006) LA Paliperidone (2009) Iloperidone & Asenapine (2009) LA Olanzapine (2010) Lurasidone (2010)
LA typicals
Highly effective in reducing relapse of schizophrenia High rates of non-adherence to oral medication non(up to 42%)
Second generation antipsychotics generated hope to increase medication adherence Many epidemiological analyses show not much difference between second generation and conventional antipsychotics
Drug
Tablet or Capsule
Aripiprazole Asenapine Clozapine Iloperidone Lurasidone Olanzapine Paliperidone Quetiapine Risperidone Ziprasidone =formulary at HMC = nonformulary at HMC
Knowing the appropriate injection site Using the correct needle length Rotating sites when appropriate
Nodules and indurations Muscle granulomas Fibrosis Abscess formation Observed in up to a quarter of patients
Indicated for the treatment of schizophrenia or as monotherapy or adjunct therapy in maintenance treatment of bipolar First second generation long acting IM antipsychotic Administered every two weeks Requires oral overlap for at least three weeks Complicated kinetics
LA Risperdal Consta
Aqueous suspension Active drug is encapsulated in a microsphere of polylactide-copolylactide-co-glycolide polymer Gradually released as microsphere copolymer which is hydrolyzed over several weeks
Majority released during weeks 4-6 4-
LA Risperdal Consta
PO Risperidone 1 mg 2 mg 3 mg 4 mg
LA Risperidal Consta
First establish tolerability with oral risperidone Requires refrigeration but can be kept at room temperature for 7 days Allow dose pack to come to room temperature prior to reconstitution Must be administered within 6 hours after reconstitution Resuspension by shaking necessary if not given within 2 minutes of reconstitution
LA Risperidal Consta
Kit includes:
Risperidone extended-release microspheres extendedOne pre-filled syringe containing 2 mL of diluent preOne SmartSite Needle-Free Vial Access Device NeedleOne 21 gauge 1 inch needle for deltoid injection One 20 gauge 2 inch needle for gluteal injection
LA Risperdal Consta
Steady state plasma concentrations achieved after 4 injections Maintained 4-6 weeks after last injection 4Deltoid and gluteal injections are interchangeable and bioequivalent
LA Risperidal Consta
Indicated for the treatment of schizophrenia Once monthly injection Aqueous based formulation Manufacturer claims no overlap required with oral therapy No refrigeration
LA Invega Sustenna
Prefilled syringes Needle size into deltoid muscle determined by patients weight
For those >90 kg or 200 lbs use 1.5 inch, 22 gauge needle For those <90kg or 200 lbs use 1 inch, 23 gauge needle
Injection in the gluteal muscle requires the 1.5 inch, 22 gauge needle Shake syringe vigorously for a minimum of 10 seconds prior to attaching the needle
LA Invega Sustenna
First establish tolerabilty with po risperidone or paliperidone Begin with initial loading dose of 234 mg Give second shot of 156 mg 7 days later (+/- 2 (+/days)
First two injections must be administered in deltoid muscle
LA Invega Sustenna
PO Invega 12 mg 9 mg 6 mg 3 mg 1.5 mg
LA Invega Sustenna
Managing Missed Doses: Time Interval of Missed Dosing Schedule Dose From 1 month to 1.5 months 1.5 months to 6 months since last injection > 6 months since last injection Resume injections as soon as possible Dose and Injection Site Previously administered maintenance dose in the deltoid muscle
Two injections, one week Previously administered apart maintenance dose in the deltoid muscle** De novo with suggested initiation regimen 234/156 mg on days 1/8 in the deltoid muscle followed by monthly maintenance dose
**Unless the patient was stabilized on 234 mg in which case the first two injections should be 156 mg each
LA Invega Sustenna
Indicated for the treatment of schizophrenia Intended for deep intramuscular gluteal injection only Must establish tolerability with po olanzapine prior to use Not to be confused with short-acting IM shortZyprexa
LA Zyprexa Relprevv
Slow dissolution of a crystalline salt Crystals are micron-sized and suspended in micronwater When injected into muscle, the salt slowly dissolves and dissociates into separate molecular entities of olanzapine and pamoic acid
LA Zyprexa Relprevv
Injections every 2-4 weeks provides olanzapine 2concentrations similar to daily doses of oral olanzapine life of Zyprexa Relprevv is 30 days Plasma concentrations peak within a week of injecting and are at trough level immediately prior to next injection
LA Zyprexa Relprevv
Dose of Zyprexa Maintenance Relprevv first 8 Dose of Zyprexa weeks Relvprevv after initial 8 weeks 210 mg/2 weeks or 405 mg/4 weeks 300 mg/2 weeks 150 mg/2 weeks or 300 mg/2 weeks 210 mg/2 weeks or 405 mg/4 weeks 300 mg/2 weeks
10 mg/day
15 mg/day
20 mg/day
LA Zyprexa Relprevv
Kit includes:
Vial of Zyprexa Relprevv powder 3-mL of diluent One 3 mL syringe with pre-attached 19 gauge, pre1.5 inch needle Two 19 gauge, 1.5 inch needles
For obese patients, use a 2 inch, 19-gauge or 19larger needle (Not included in kit)
LA Zyprexa Relprevv
Must be suspended using only the diluent supplied in kit Reconstitution is complicated and specific to dose If foam forms, let vial stand to allow foam to dissipate If product not used right away, shake vigorously to reresuspend should appear smooth and consistent in texture and color (yellow and opaque)
LA Zyprexa Relprevv
Before administering, confirm there will be someone to accompany the patient after the 3 hour observation period If this cannot be confirmed, do not give the injection Remains stable up to 24 hours in the vial
LA Zyprexa Relprevv
Must be administered in a registered healthcare facility with ready access to emergency response services
LA Zyprexa Relprevv
LA Zyprexa Relprevv
Documented risk of post-injection syndrome is post0.07% Risk of syndrome occurring in a single patient for 20 years is 5%
LA Zyprexa Relprevv
LA Aripiprazole LA Iloperidone
LA Injections to Come?